Lisfranc Fracture

Lisfranc Fracture and/or dislocation is an injury characterized by disruption between the medial cuneiform and base of the 2nd metatarsal.

The incidence of Lisfranc injuries is rare, but approximately 20% of Lisfranc injuries are initially overlooked.

Lisfranc injury can be either a bony injury or ligamentous injury (Lisfranc ligament tear). Lisfranc ligament is an interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface, it’s critical to stabilizing the second metatarsal and maintenance of the midfoot arch.

The Lisfranc joint complex consists of the tarsometatarsal, intermetatarsal and intertarsal joints. Injuries of the tarso-metatarsal articulation range from mild sprains to widely displaced debilitating injuries.

See Also: Foot Anatomy

Mechanism of Injury

Injuries of the Lisfranc joint complex result from either direct or indirect mechanisms.

Direct Lisfranc injury results from a dorsally applied force. This results in either plantar metatarsal displacement if the force is applied to the metatarsal base, or dorsal metatarsal displacement if the force is applied to the cuneiforms. There is a high incidence of associated tarsal fracture, significant soft-tissue destruction and compartment syndrome.

Indirect Lisfranc injury occurs from a combination of axial loading and twisting on an axially loaded, plantarflexed foot. Because of the mechanism of injury, relatively weaker dorsal ligaments and greater mobility between the first and second metatarsals, the displacement is typically dorsal with diastasis between the first and second metatarsals and their corresponding cuneiforms.

Lisfranc Fracture Symptoms

Patients with Lisfranc Fracture present with pain, variable swelling, foot deformity and tenderness on the dorsum of the foot.

Neurovascular examination is essential, as Lisfranc joint dislocation may be associated with impingement on or laceration of the dorsalis pedis artery.

Severe foot swelling is common with high-energy injuries and serial neurovascular examination or compartment pressure monitoring is required to evaluate for compartment syndrome.

Radiology

Anteroposterior, internal oblique and lateral foot radiographs are obtained to evaluate the tarsometatarsal articulations.

Despite normal radiographs, if injury is suspected, a CT scan can be used to assist in the diagnosis. A CT scan will show the osseous structures as well as the amount of intra-articular comminution. Associated fractures of the cuneiforms, cuboid and/or metatarsals are common and should be looked for.

Classification

Classification schemes for Lisfranc injuries guide the clinician in defining the extent and pattern of injury, although they are of little prognostic value.

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Quenu and Kuss Classification

This classification is based on commonly observed patterns of injury:

Homolateral	All five metatarsals displaced in the same direction
Isolated	One or two metatarsals displaced from the others
Divergent	Displacement of the metatarsals in both the sagittal and coronal planes

Myerson Classification

This is based on commonly observed patterns of injury with regard to treatment:

Total incongruity	Lateral and dorsoplantar dislocation
Partial incongruity	Medial and lateral dislocation
Divergent	Partial and total dislocation

Lisfranc Fracture Treatment

Non-surgical treatment for Lisfranc fracture is used for patients with ligamentous injuries with or without small plantar avulsion fractures of the metatarsal/tarsal bones and non-displaced fractures. This consists of:

1. A non- weight-bearing wellmoulded short leg cast for 8 weeks,
2. followed by gradual weight bearing in a removable boot brace.
3. Repeat radiographs are necessary once the swelling decreases to detect osseous displacement.

Lisfranc Fracture Surgery treatment is performed for injuries with >2 mm displacement of the tarsometatarsal joint. If anatomic reduction can be obtained by closed means, percutaneous internal fixation can be performed. But an interposed Lisfranc ligament remnant can frequently block reduction and result in the joint springing open, once internal fixation is removed. Therefore, open reduction is frequently necessary through a single or dual longitudinal incision as dictated by the injury pattern.

The key to reduction is correction of the fracture dislocation of the second metatarsal base. Fixation is achieved with 4.0 mm screws for the medial (first tarsometatarsal joint) and middle (second, third tarsometatarsal joints) columns and Kirschner wires for the lateral (fourth, fifth tarsometatarsal joints) column.

A severe abduction mechanism may result in compression of the cuboid, which may require lateral plating and bone grafting to avoid residual abduction. Fixation allows arthrofibrosis of the injured joints, which preserves the normal slope of the foot. Patients should not bear weight for 8 weeks, followed by gradual weight bearing in a removable boot brace.

Implant removal is usually performed to avoid breakage and to restore tarsometatarsal motion. Lateral column stabilization can be removed at 6–12 weeks; however, medial fixation should not be removed for 4–6 months. Some authors advocate that, although screw breakage can occur, it is preferable to leave the screws in place as removal can lead to planovalgus deformity.

Immediate complete arthrodesis of the midfoot has been associated with poor results, although partial arthrodesis tends to have better results than complete arthrodesis.

References & More

1. Peicha G, Labovitz J, Seibert FJ, et al. The anatomy of the joint as a risk factor for Lisfranc dislocation and fracturedislocation: an anatomical and radiological case control study. Journal of Bone and Joint Surgery (British) 2002;84:981–5. Pubmed
2. Aitken AP, Poulson D. Dislocations of the tarsometatarsal joint. Journal of Bone and Joint Surgery (American) 1963;45:246. Pubmed
3. Quenu E, Kuss G. Etude sur les luxations du metatarse du diastasis entre le 1er et le 2e metatarsien. Revue de Chirurgie 1909;39:281–336.
4. Myerson M, Fisher R, Burgess A, et al. Dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot and Ankle 1986;6:225.
5. Teng AL, Pinzur MS, Lomasney L, et al. Functional outcome following anatomic restoration of tarsal-metatarsal fracture-dislocation. Foot and Ankle International 2002;23:922-6.
6. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfrancs injuries: primary arthrodesis or ORIF? Foot and Ankle International 2002;23:902–5.
7. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.